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Based on record review and staff interview, the facility failed to include discharge planning in Biopsychosocial Assessments for 8 of 8 active sample patients (A1, A2, A3, A4, A11, A14, A16 and A17). This deficiency potentially prolongs hospital stay and prevents patients from having all available community resources utilized.

Findings include:

A. Record review

1. The Biopsychosocial Assessment for patient A1 (dated 05/02/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. The assessment was concluded with "clinical impression" that stated, "Ct [client] referred to current placement due to continued deterioration of mental health.... Ct cooperative and willing to engage in conversation." No social work plan was mentioned.

2. The Biopsychosocial Assessment for patient A2 (dated 06/21/10) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical Impression" concluded the assessment and stated, "[Name of patient] had specific emotional, behavioral and educational problems to be addressed.... Recommendations will agree with the treatment team and doctor regarding the safety of the client and others. Monitor closely for suicidal behaviors, elopement and substance abuse. Place in behavior management program. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

3. The Biopsychosocial Assessment for patient A3 (dated 01/16/2011) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "[Name of patient] had specific emotional, behavioral and educational problems to be addressed.... Monitor closely for suicidal behaviors, self-injurious behaviors, aggression and elopement. Place in behavior management program. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

4. The Biopsychosocial Assessment for patient A4 (dated 01/14/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "Ct transferred from another residential placement due to reaching her peak expectations at previous placement. Ct history of running away, substance abuse, property destruction, and truancy.... Ct able to identify a variety of coping skills and goals for current placement." No social work plan was mentioned.

5. The Biopsychosocial Assessment for patient A11 (dated 03/04/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "[Name of patient] had specific emotional, behavioral and educational problems to be addressed.... Monitor closely for suicidal behaviors, self-injurious behaviors, aggression, elopement, substance abuse and high-risk sexual behaviors. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

6. The Biopsychosocial Assessment for patient A14 (dated 02/09/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "Ct admitted for repetitive aggressive behaviors and elopement.... Current goals are to increase periods of stability and learn and implement positive thinking skills." No social work plan was mentioned.

7. The Biopsychosocial Assessment for patient A16 (dated 10/12/10) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "Ct was referred to treatment due to high risk behaviors such as daily use of drugs, sexually acting out, fire setting and self harm.... At time of assessment, ct was cooperative...." No social work plan was mentioned.

8. The Biopsychosocial Assessment for patient A17 (dated 04/18/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "[Name of patient] has specific emotional, behavioral and educational problems to be addressed.... Monitor closely for self-injurious behaviors, aggression, elopement, and substance abuse. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

B. Interviews

1. In an interview on 05/23/11 around noon, social worker #1 stated, "discharge functions are done by the case managers (who are not social workers). Social workers do not do those. They do therapy."

2. In an interview on 05/24/11 at 9:30a.m., the Biopsychosocial Assessments were discussed with the Director of Social Work. She agreed with the findings.

Based on record review and staff interview, the facility failed to assess patient memory in the Psychiatric Evaluations for 2 of 8 active sample patients (A14 and A17). This deficiency makes it impossible to follow the changes of these parameters and adjust treatment accordingly.

Findings include:

A. Record Review

1. The Psychiatric Evaluation for patient A14 (dated 02/08/11) did not include any statement about patient memory.

2. The Psychiatric Evaluation for patient A17 (dated 04/16/11) did not include any statement about patient memory.

B. Interview

In an interview on 05/24/11 at 9a.m. the Medical Director agreed with the findings.

Based on record review and interview, the facility failed to provide Master Treatment plans which contained treatment interventions by the attending physician for 5 of 8 active sample patients (# A4, A11, A14, A16 and A17). An additional 2 of 8 active sample patients (A2 and A3) contained one identical non-specific generic physician intervention. These failures compromise the effective leadership, coordination, and direction of care provided to patients.

Findings include:

I. Failure to include physician intervention on all Master Treatment plans

A. Facility policy titled "Long-Term Adolescent Programs Treatment Plan/Permanency Plan", procedure # 2201-4, dated 8/1/07, stated under Comprehensive Treatment Plan - "The treatment plan is developed by the following individuals: client, psychiatrist, therapist.... The treatment plan forms the basis for all chart-program assignments and staff objectives for interactions and treatment." The policy did not specifically state that a physician must be included on the plan even though a physician is present (as evidenced by signature and date) at the Treatment team meetings.

B. The following patients' Master Treatment plans did not contain physician interventions (dates of development and/or review in parentheses): A4 (5/14/11), A11 (5/1/11), A14 (5/17/11), A16 (5/14/11), and A17 (5/16/11).

C. In an interview with the Medical Director on 5/24/11 at 9:00a.m., the lack of physician interventions on the Master Treatment plan was discussed. She did not dispute the findings.

II. Failure to include more specific physician intervention on two Master Treatment plans

A. Active sample patient A2, Master Treatment plan reviewed 5/9/11

Problem - "Suicidal risk"
Short term goal (objective) - "[Name of patient] will comply with precautionary procedures to maintain her safety as ordered for the next three months."
Physician intervention - "Psychiatrist will monitor and order precautions as necessary."

B. Active sample patient A3, Master Treatment plan dated 5/9/11

Problem - "Suicidal ideations"
Short term goal - "[Name of patient] will comply with precautionary procedure to maintain her safety as ordered for the next three months."
Physician intervention - "Psychiatrist will monitor and order precaution as necessary."

The physician intervention for the two patients listed above were generic tasks expected of any physician.

C. In an interview on 5/24/11 at 9:00a.m., the lack of specific physician interventions on the Master Treatment plans was discussed with the Medical Director. She acknowledged the findings.

Based on record review and interview, the Medical Director failed to adequately monitor the care provided patients at the facility. Specifically the Medical Director failed to:

I. Assure that all patient records included an assessment of patient memory. The assessment was lacking for 2 of 8 active sample patients (A14 and A17). This deficiency makes it impossible to follow the changes of these parameters and adjust treatment accordingly.

II. Ensure that physician interventions were included on the Master Treatment plans for 5 of 8 active sample patients (A4, A11, A14, A16, and A17) and that physician interventions for 2 of 8 active sample patients (A2 and A3) were related to specific patients' needs, not generic tasks expected of a physician. These failures compromise the leadership, coordination, and direction of care provided to patients.

Findings include:

I. Failure to include an estimate of memory in the Psychiatric Evaluation

A. Record Review

1. The psychiatric assessment for patient A14 (dated 02/08/11) did not include any statement about patient memory.

2. The psychiatric evaluation for patient A17 (dated 04/16/11) did not include any statement about patient memory.

B. Interview

In an interview on 05/24/11 at 9a.m. the Medical Director agreed with the findings.

II. Failure to include individualized physician interventions on all Master Treatment plans

A. Facility policy titled "Long-Term Adolescent Programs Treatment Plan/permanency Plan", procedure # 2201-4 dated 8/1/07, stated under comprehensive treatment plan "the treatment plan is developed by the following individuals: client, psychiatrist, therapist.... The treatment plan forms the basis for all chart-program assignments and staff objectives for interactions and treatment." The policy did not specifically state that a physician must be included on the plan even though a physician is present (as evidenced by signature and date) at the Treatment team meetings.

B. The following patients' Master Treatment plans did not contain physician interventions (dates of development and/or review in parentheses): A4 (5/14/11), A11 (5/1/11), A14 (5/17/11), A16 (5/14/11), and A17 (5/16/11).

C. Two MTPs reviewed contained only a generic physician intervention:

1. Active sample patient A2, Master Treatment plan reviewed 5/9/11:

Problem - "Suicidal risk"
Short term goal (objective) - "[Name of patient] will comply with precautionary procedures to maintain her safety as ordered for the next three months."
Physician intervention - "Psychiatrist will monitor and order precautions as necessary."

2. Active sample patient A3, Master Treatment plan dated 5/9/11:

Problem - "Suicidal ideations"
Short term goal - "[Name of patient] will comply with precautionary procedure to maintain her safety as ordered for the next three months."
Physician intervention - "Psychiatrist will monitor and order precaution as necessary."

The physician interventions for the two patients listed above were generic tasks expected of any physician.

D. In an interview on 5/24/11 at 9:00a.m., the lack of specific physician interventions on the Master Treatment plan was discussed with the Medical Director. She acknowledged the findings.

Based on record review and staff interview, the Social Work Director failed to insure that discharge planning was included in Biopsychosocial Assessments for 8 of 8 active sample patients (A1, A2, A3, A4, A11, A14, A16 and A17). This deficiency potentially prolongs hospital stay and prevents patients from having all available community resources utilized.

Findings include:

A. Record review

1. The Biopsychosocial Assessment for patient A1 (dated 05/02/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. The assessment was concluded with "clinical impression" rather than the plan. It stated, "Ct [client] is referred to current placement due continued deterioration of mental health"... "Ct cooperative and willing to engage in conversation." No social work plan was mentioned.

2. The Biopsychosocial Assessment for patient A2 (dated 06/21/10) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical Impression" concluded the assessment and stated, "[Name of patient] had specific emotional, behavioral and educational problems to be addressed... Recommendations will agree with the treatment team and doctor regarding the safety of the client and others. Monitor closely for suicidal behaviors, elopement and substance abuse. Place in behavior management program. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

3. The Biopsychosocial Assessment for patient A3 (dated 01/16/2011) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "[Name of patient] had specific emotional, behavioral and educational problems to be addressed"... "Monitor closely for suicidal behaviors, self-injurious behaviors, aggression and elopement. Place in behavior management program. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

4. The Biopsychosocial Assessment for patient A4 (dated 01/14/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "Ct transferred from another residential placement due to reaching her peak expectations at previous placement. Ct history of running away, substance abuse, property destruction, and truancy"... "Ct able to identify a variety of coping skills and goals for current placement." No social work plan was mentioned.

5. The Biopsychosocial Assessment for patient A11 (dated 03/04/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "[Name of patient] had specific emotional, behavioral and educational problems to be addressed"... "Monitor closely for suicidal behaviors, self-injurious behaviors, aggression, elopement, substance abuse and high-risk sexual behaviors. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

6. The Biopsychosocial Assessment for patient A14 (dated 02/09/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "Ct admitted for repetitive aggressive behaviors and elopement"... "Current goals are to increase periods of stability and learn and implement positive thinking skills." No social work plan was mentioned.

7. The Biopsychosocial Assessment for patient A16 (dated 10/12/10) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "Ct was referred to treatment due to high risk behaviors such as daily use of drugs, sexually acting out, fire setting and self harm"... "At time of assessment, ct was cooperative..." No social work plan was mentioned.

8. The Biopsychosocial Assessment for patient A17 (dated 04/18/11) did not include any information on where the patient was supposed to return when discharged from the facility and what the social worker would be doing to ensure utilization of available community resources. "Clinical impression" concluded the assessment and stated, "[Name of patient] has specific emotional, behavioral and educational problems to be addressed"... "Monitor closely for self-injurious behaviors, aggression, elopement, and substance abuse. Monitor peer interactions. Encourage medication compliance. Immediately address level of motivation." Those were not specific social work functions.

B. Interviews

1. In an interview on 05/23/11 around noon, social worker #1 stated, "Discharge functions are done by the case managers (who are not social workers). Social workers do not do those. They do therapy."

2. In an interview on 05/24/11 at 9:30a.m. the Director of Social Work agreed with the findings.